"What we really need are more progressive lenses to choose from. Do you hear that a lot? No, me neither.

Lens manufacturers have been releasing new lenses at an incredible rate for several years nowespecially progressive addition lenses (PALs). It seems that hardly a month goes by without a new PAL on the market, yet almost all the old PAL designs are still around. One particular lens manufacturer now has more than 100 different PAL offerings in more than two dozen different designs. So, how do you know which PAL will be a good fit for your patient?

Choose your PALs Carefully

Actually, its easier than it might seem, thanks to todays modern manufacturing techniques and computer-aided designs. There are many very good PALs on the market now and, if fit properly, very few patient adaptation problems. Nearly every lens manufacturer has an assortment of designs, materials, and colors available so that each PAL can be customized for each patients needssuch as general-purpose lenses, short-corridor lenses or task-specific lenses. Many are also available in polarized or photochromic versions. A practice can stay loyal to one or two manufacturers that offer a variety of PAL designs. Or, a practice can strive to find the one, unique PAL design that best complements each particular patients vision.

How do you select the best designs to offer in your practice? Start by listening to what the sales reps say about their lenses. However, before you make any sort of decision, do your own research on the different designs, develop your own preferences, and then you can cherry-pick the most appropriate design based on your patients visual needs.

Then again, keeping up with the latest PAL products on the market can be challenging. In the last year, major lens companies Essilor, Shamir Insight, Signet Armorlite, KBco, Seiko, X-Cel, Hoya and Carl Zeiss Vision have all released new PAL designs (Essilor actually came out with four new designs in the last year). In addition to entirely new PAL designs, manufacturers are also constantly introducing new materials in their existing designs. Every office needs to have someone in charge of keeping the office up-to-date with these new materials and designs. Your patients will be best served if you offer the newest designs and/or materials to match their needs. This information can be obtained from your labs, at meetings or at continuing education seminars.

However, many labs only support certain lens brands and, like that friendly lab rep, may tend to recommend only the ones they distribute or carry in stock. If you use a lab that carries a lot of different PAL brands, you may get better, unbiased advice on what to offer a particular patient. So many new products are constantly being produced that you need to be sure your lab keeps up with the latest releases and can provide your practice with the latest information, literature and training.

Matching the best lens design to your patient requires that you know both.

Guidelines for Fitting PALs

Know your PALs. Be familiar with as many of the myriad PAL designs as you can and understand how they can work for different types of vision needs. Consider the specialized designs such as near-variable-focus occupational progressive lenses (OPLs) for the avid hobbyist who practically lives in his workshop or the AO bActive PAL for the avid outdoorsman who needs clear periphery vision. A presbyopic dental hygienist may benefit from an OPL such as an AO Technica, Hoya Tact or Zeiss Gradal RD. And of course the myope who adores the wrap sunglasses in your dispensary will be delighted with a Shamir Attitude PAL or KBco EOS Wrap, made specifically for minus Rxs in wrap frames.
Play matchmaker. Matching the best lens design to your patient requires that you know both. A lifestyle questionnaire or checklist can be helpful at this pointbut its not a replacement for getting to know your patient. Listen carefully to each patient. If he or she isnt the talkative type, then ask directly about work, activities and hobbies. Consider that this patient may have given up an activity because of vision difficulties, so be sure to also ask your patient what he or she would like to be able do.

If this is the patients first PAL, or even a change from his or her current PAL, then talk about adapting to the new lenses. Explain the features and benefits of the lenses and what to expect. Talk about how the patient will use the lenses and how he or she will be more comfortable during his or her regular routine, as well as while engaging in favorite activities. While helping the patient choose frames, explain the importance of choosing the right size and style of frame that best matches the lens prescription and vision needs.

Help with PAL Performance

A great resource for unbiased PAL design information, detailing the performance qualities and actual viewing zone measurements of many PALs, are several outstanding publications located on a Web site by Ohio State Universitys Center for Ophthalmic Optics Research: http://optometry.osu.edu/research/COOR/index.cfm.

You just might be surprised how your favorite PALs-of-choice are ranked. The site also details occupational progressive lenses (OPLs) and the specific vision requirements of dozens of occupations and sports activities. Some of the newest PALs may not yet be evaluated on this site, so check with your lab for the latest information.

Does Your PAL Measure Up?

No PAL design will work well if the proper measurements are not taken correctly and precisely.

Use a pupillometer to measure monocular pupillary distance (PD). Adjust the frame completely to the way the patient will actually wear it. Let the patient get comfortable wearing the frame before taking any measurements.
Ensure a proper fit. Ideally, the vertex distance should be 11mm to 14mm and the pantascopic tilt 8 degrees to 14 degrees.

Measure monocular pupil (seg) heights by dotting the demo lens (or transparent tape if no demos) then drawing a horizontal line through the dots. By drawing a line, you will be able to check if the dot is indeed at the center of each pupil and easily measure to the deepest points of the frame on each side, not just the points directly below the pupil dots. When measuring, work at the same level as the patient to avoid parallax error.

Verify lens cutout using the lens manufacturers cutout chart. Make sure the fitting height is within the lens manufacturers recommended minimum fitting height guidelines. Your lab can provide that information if necessary. If the lens wont cut out, or if the fitting height is too low, then choose another, more appropriate lens.

Dont Forget the Second Pair

The perfect time to discuss second-pair purchases is while you explain the basic concepts of PALs to your patient. Of course, we all automatically consider sunwear as a natural choice for a second pair; most PALs come in a polarized version and, since everyone goes outside, its a no-brainer

But task-specific eyewear, on the other hand, is often overlooked. Many people spend much of the day in working environments where they use near and intermediate vision almost exclusively. Yet, they are rarely offered lenses specifically for those room-size distances. Near-variable-focus lenses and occupational progressive lenses (OPLs) are an excellent second- (or third-) pair option for all patients being fitted for general purpose PALs. Consider offering a discount for that second pair to your patients. Many labs will also extend a discount for a second order within a specified period of time.

New PALs, Coming Up!

Submit. Submitting your order to the lab should be easy. Nearly all lab orders are now placed via Internet portals; Internet orders speed up turnaround time and reduce errors due to redundant data entry. Internet orders also minimize phone calls from the lab requesting pertinent information that was inadvertently left off the paper Rx forms.
Verify. Verify the order when you receive the completed eyewear from the lab. This is crucial for responsible dispensing, and with some managed vision-care plans, its required. Do it as soon as possible upon receiving the order. If theres a problem requiring a reorder, you may have to reschedule the patients appointment, and that is much easier to do before the patient comes in to pick up the new spectacles.

Make sure to confirm the PD, seg height and prescription. Use the engravings on the lens surface to verify the add powers. If you are unsure of the engravings on each lens, contact your lab or refer to the OLA Progressive Lens Identifier publication.

Dispense. Dispense the finished eyewear to your patient in a relaxed setting. Allow each patient plenty of time for the appointment, and prepare the patient to spend some time getting to know his new eyewear, especially a first-time PAL-wearer. Present the eyewear to the patient and discuss the accommodation process. Make sure the patient fully understands the differences between the new lenses and the old lenseseven if you have to review the basic concepts of PAL designs again.
Fine tune. Lastly, fine tune the final fit of the frame on your patient. Verify that the fitting cross is at the center of the pupil by using the lab-provided decals. Remove the decals, clean the lenses, and let the patient begin to acclimate to the new lenses.

Offer the patient reading material with different size print available to demonstrate the near prescription zone of the lenses. Let your patient experiment with the reading material and move it around while holding his or her head still while looking through the periphery of the lenses.

Next, have the patient experiment with the different zones of the lens, looking at objects an arms length away, then at objects across the room (at least 20 feet away). Finally, have the patient sweep his or her line of sight through all the zones: direct the patient to look across the room, gradually move down through the intermediate corridor, and finally into the near zone to view the reading material again.

As your patient gets used to the new lenses, instruct him or her on care and cleaning of the eyewear. Make sure to tell each patient exactly how to clean the new lenses, and what cleaning agents to use or not use. This instruction may vary depending on whether the lenses have any coatings on them, such as an anti-reflective coating. Youll do your patients two services this way: one, they have more time to become accustomed to their new PALs, and two, they know how to properly care for their lenses.

PAL Quick Reference Guide 
(General guide only, in no particular order)

Clear Distance
Younger Image, Shamir Genesis, Zeiss Gradal Top, AO bActive, Vision-Ease Outlook, Hoya ECP, Polycore Micro, Signet Armorlite Kodak, Rodenstock Life AT

Wide Intermediate Zones

Zeiss Gradal Top & Gradal Brevity, Hoya ECP, Essilor Definity, Pentax AF & AFmini, SolaMAX, Polycore Futurise, Signet Armorlite Kodak, AO Pro, Varilux Liberty

Large Reading Zones

Varilux Comfort, Shamir Piccolo, SolaMAX, Rodenstock Life XS, Kodak Precise, Hoya GP Wide, AO Compact, Vision-Ease Illumina, Seiko Proceed II Short, Zeiss GT2

Occupational PALs and Near Variable Focus (NVF) Lenses

Zeiss Gradal RD (Room Distance), AO Technica, Hoya Tact, Essilor Interview, Shamir Office, Zeiss Business, Sola Access, Prio PCL/Browser

Troubleshooting PALs

Dont jump to conclusions when an unsatisfied patient returns with complaints about the new lenses. They may not need to be remade! Start by asking the patient why he is unsatisfiedit may simply be a matter of buyers remorse regarding the frame style or color. (If youve ever heard a patient say, Well, as long were remaking the lenses, I think Id like to pick out a different frame, too, youve experienced buyers remorse firsthand.)

Maybe the patient is using the eyewear in different conditions than originally described to you. After youve determined that its more than just buyers remorse, ask as many questions as you can. Ask your patient to demonstrate the glasses: Does he or she wear them above the bridge of the nose, or below it? Are they worn mainly for close-up work, or while working on a computer for long hours? Did the patient follow your guidelines about moving his head and pointing his nose, or is he looking through the periphery of the lenses?

Finally, observe the patient as he or she uses the lenses. Does he move his head up or down to read? If so, the seg height may be off. Try adjusting the frame fit to compensate. However, if the patient moves reading material to one side to focus, then the PD is probably off, and the lenses will have to be remade. Check the lenses and re-measure the patient with a pupillometer.

If the patient complains of a narrow reading area, adjust the pantascopic tilt of the frame and try to fit it closer to the face, if possible. If the reading zone is still too narrow, the fitting height may be too low, or a different PAL design with a larger reading zone may be requiredagain, the lenses will have to be remade.

Get it Right or Get Lost

Most professionals would shudder at the thought of someone in their office dispensing eyewear without verifying the prescription, but it does happen. I know, because it actually happened to me when I first got glasses at the age of 10, and Ill never forget the experience. Even after complaining of eyestrain and poor vision for the first week, the doctor claimed I simply needed to get used to wearing glasses. Finally, after my parents insisted the glasses be inspected, it turned out my prescription had been switched with someone elses. I eventually got the correct prescription, wonderfully clear vision, and a new doctor. In fact, come to think of it, my whole family got a new doctor!

Blurry peripheral vision is a common complaint that can sometimes be solved by increasing the facial wrap of the frame. If that doesnt help, the fitting height may be too high; when reordering, specify a different PAL design with a wide, clear distance zone.

Make sure to follow up with each PAL patient within five days to see how he or she is doing with the new eyewear. Ask if he or she has any questions or concerns (avoid using the word problems as that may stimulate the patient to think he or she should be having problems), and thank the patient for his or her business. Each patient will value your thoughtfulness and consideration. And, now that your patients are satisfied with their new PALs and they know that you are doing your best so their vision is at its best, they just might want to schedule an appointment for another pair.

Mr. Brown is a 21-year veteran of the optical business. He is the lens buyer and analyst for a major optical laboratory.

Vol. No: 144:01Issue: 1/15/2007